Use of the fibula free flap was pioneered at Memorial Sloan-Kettering, Dr. Huryn said. This procedure entails removing the fibula (not a weight-bearing bone, he noted) and carving the bone to mimic the shape of the lower jaw. Teeth are implanted into the bone, allowing the patient to chew and swallow normally.
Explore This IssueFebruary 2009
Dr. Davis described a palatal lift, which is used to restore velopharyngeal competence for patients whose soft palates don’t move. Patients who have soft palate insufficiency can have a speech bulb prosthesis to allow speech and swallowing. Palatal augmentation devices can be placed if part of the tongue has been resected; this procedure lowers the palatal floor to make contact with the tongue and enables swallowing, she said.
Who Should Have a Prosthetic Device?
The decision between surgical reconstruction and a prosthetic device is based on a number of factors, including age, cormorbidities, general health status, patient preference, and reimbursement. In general, larger defects are more amenable to a surgical reconstruction. Older, medically compromised patients may prefer prosthetics, whereas younger patients tend to opt for surgical reconstruction when possible, Dr. Davis said.
In the cancer setting, indications for prosthetics depend largely on patient preference. A significant proportion of patients don’t pursue prosthetic procedures. They will just use a patch over a missing eye. If the ear is missing, they will accept living with a flat spot, and they may just leave the nose defect as is. Some people choose to wear surgical masks to avoid stares. It can be a reimbursement issue, or they may not be candidates for prosthetic rehabilitation, or simply, cancer patients may be tired of surgery, Dr. Skoracki said.
Mr. Gion said that a prosthesis is advisable for a head and neck cancer patient who needs ongoing monitoring of the area of the face at risk for recurrence. Some surgical reconstructions are too complicated to attempt-an ear, for example-and in that situation a prosthetic device is preferable.
Prosthetic devices are not a good choice for patients with poor vision and poor manual dexterity who may not be capable or motivated to manage the prosthetic and clean it, Mr. Gion continued.
Another important consideration is access to rehabilitation, Dr. Huryn noted. A military patient may have a prosthetic device procedure at a state-of-the-art hospital, but then go home to a rural area where rehabilitation is not available. In that case, a prosthetic device may not be a good option, he commented.